Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach management of a patient who develops squamous cell skin cancer while on abatacept?
I would discontinue abatacept. Several studies now have reported an increased risk of squamous cell cancer/non-melanoma skin cancers in patients on abatacept (Wadstrom et al., PMID 28975211, Simon et al., PMID 37932010) and in someone who actually develops this malignancy on the drug, I would hesita...
When trying to increase infliximab for active disease (inflammatory arthritis or sarcoidosis), do you prefer to increase dosage or reduce frequency between doses?
As is often the case with rheumatology therapeutics, we are residing in a " data-free" zone. There is limited literature available from the Crohn's disease patient population where this issue was studied in a limited way. There did not appear to be any significant difference in outcome using either ...
What is your approach to patients with biopsy proven giant cell arteritis that continue to have symptoms after initiation of high dose glucocorticoid therapy?
First, let's define and discuss “high-dose” steroids. Oral therapy is typically 60-100 mg of prednisone daily, and IV is 500-1000 mg of methylprednisolone daily for three days, followed by oral prednisone. There has been no difference in long-term outcomes for vision loss or diplopia. The complicati...
Do you escalate treatment in patients with myositis who achieve clinical remission but continue to have elevated CPK?
Typically, patients who are doing well and in remission can have low levels of CK abnormality, which needs to be monitored but not treated. Post myositis improvement, some patient's muscle membrane remains leaky or not perfect, leading to some low levels of elevated CK, which has no clinical signifi...
What is your approach to timing of medications like Rituximab and Cyclophosphamide around plasmapheresis in patients on daily PLEX?
Plasma exchange (PLEX) in designed to remove antibodies. Thus, PLEX will remove monoclonal antibodies, including rituximab, and do so fairly effectively and likely to some extent in proportion to the intensity of the PLEX. If there is a clinical need to use PLEX for a patient also to be given rituxi...
When would you consider discontinuing immunosuppressive treatment in a quiescent uveitis patient without systemic manifestations of inflammation?
I typically monitor patients on immunosuppressive therapy for at least 2 years before considering stopping or weaning off such therapy. There could be exceptions to this, including patients who insist on being taken off their meds (side effects, trying to conceive, etc.), in which case I can try aft...
How do you think about using Ropeginterferon Alfa 2B for polycythemia vera in patients with active autoimmune disease?
Great question. In general, I avoid interferons in patients who have an autoimmune disease. In the PROUD-PV/CONTI-PV study, a medical history of autoimmune disease was an exclusion criterion. There have been reported cases of interferon-induced autoimmune disease, most commonly autoimmune thyroiditi...
Do you have to extend treatment for acute Lyme disease if a patient is on high dose steroids for another indication?
I am unaware of any evidence to support longer-term therapy in such a setting. I am quite sure no such study has ever been done. Standard therapy for early Lyme disease is 10 days of appropriate antibiotics. Extending to 20 days would likely do no harm to the patient, but may not be necessary, and t...
When evaluating a patient with IgG4-related disease, are there particular exposures or risk factors you routinely ask about during the history to help identify potential contributors?
While there are no well-established environmental or occupational risk factors but taking a thoughtful exposure history can provide valuable information about the phenotype of the disease and help exclude mimics. I routinely ask about the history of allergic or atopic conditions such as asthma, alle...
How do you approach perioperative management of anabolic therapies such as romosozumab and PTH analogues in patients undergoing joint replacement?
Although there is no good human data, there is some pre-clinical data that shows increased screw purchase in the setting of tptd use. It makes good common sense that an anabolic (both PTH types and romosozumab) would likely increase the purchase of an implant. In addition, if the patient had signifi...